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2019 Hospital Compliance Assessment Checklist
All levels
U.S. Standards

2019 Hospital Compliance Assessment Checklist

Equip your hospital staff with a tool to quickly and efficiently assess compliance with the 2019 standards!

Release Date: January 15, 2019. Approximately 800 pages.

  • site license allows this ebook to be shared among unlimited users but only within one facility or site, either by posting to a secure intranet site or by providing other means of secure access. 
  • system license allows this ebook to be shared among unlimited users within all facilities or sites within a health care system, either by posting to a secure intranet site or by providing other means of secure access. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.

$199.00 - $299.00
Product Description

Product Description

A straightforward, hands-on resource, the 2019 Hospital Compliance Assessment Checklist engages staff and leadership in accreditation activities with questions, checklists, and tracer tools. This self-assessment workbook is designed to help organizations maintain continuous standards compliance and survey readiness. You have the option of reviewing high-risk or highly challenging areas in a given compliance area, or taking a more detailed look at individual elements of performance (EPs). The convenient compliance checklist includes ALL hospital standards and EPs, including those used for deemed status purposes and primary care medical home certification in the hospital setting.
 
Buy one for each member of your accreditation team, or a site license for all to share!
 
Key Topics
  • Assessment of standards compliance
  • Application of the SAFERTM Matrix
  • Evaluation of policies and procedures
  • Tracer methodology
  • Survey logistics
Key Features
  • High-level compliance prompts to help stimulate staff discussion and cultivate compliance strategies
  • Checklist with questions to assess each element of performance in the E-dition®/Comprehensive Accreditation Manual for Hospitals as of January 1, 2019
  • Tracer questions and worksheets to help with mock tracers and promote survey readiness
  • Writable PDFs (e-book only)
  • Available site license to allow accreditation prep team to share learnings and data
Standards: All hospital standards effective January 1, 2019
 
Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long term acute care, and rehabilitation hospitals
 
Key Audience
Accreditation managers
Quality improvement managers
Physician and nurse leaders
Chapter leaders and department heads
Table of Contents

Table of Contents

Draft Table of Contents
Introduction
Part 1: Prompts to Assess Your Standards Compliance
Accreditation Participation Requirements (APR)
Environment of Care (EC) 
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC) 
Information Management (IM) 
Leadership (LD) 
Life Safety (LS) 
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSG) 
Nursing (NR)
Provision of Care, Treatment, and Services (PC) 
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC) 
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
Part 2: Compliance Assessment Checklist
Accreditation Participation Requirements (APR)
Environment of Care (EC) 
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC) 
Information Management (IM) 
Leadership (LD) 
Life Safety (LS) 
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSG) 
Nursing (NR)
Provision of Care, Treatment, and Services (PC) 
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC) 
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
Part 3: Survey Logistics: Tracer Methodology and Planning Worksheets
Overview of Tracer Methodology
Conducting Mock Tracers
Worksheets for Planning a Mock Tracer
Worksheet 3-1: Mock Tracer Worksheet
Worksheet 3-2: Planning a System Tracer—Medication Management
Worksheet 3-3: Planning a System Tracer—Infection Control
Worksheet 3-4: Planning a System Tracer—Data Management
Worksheets for Conducting Program-Specific Tracers
Worksheet 3-5: Program-Specific Tracer—Suicide Prevention
Worksheet 3-6: Program-Specific Tracer—Laboratory Integration
Worksheet 3-7: Program-Specific Tracer—Patient Flow
Worksheets for Tracing the Environment of Care
Worksheet 3-8: Environment of Care—Safety
Worksheet 3-9: Environment of Care—Security
Worksheet 3-10: Environment of Care—Hazardous Materials
Worksheet 3-11: Environment of Care—Fire.
Worksheet 3-12: Environment of Care—Medical/Laboratory Equipment
Worksheet 3-13: Environment of Care—Utilities
Worksheet 3-14: Environment of Care—Construction and Other EC Considerations
Worksheets to Facilitate Hospital Logistics Planning
Worksheet 3-15: Competence Assessment Process
Worksheet 3-16: Medical Staff Credentialing and Privileging
Worksheet 3-17: Emergency Management
Worksheet 3-18: Facility Orientation—Life Safety Code Surveyor
Worksheet 3-19: Life Safety Code Building Assessment
Worksheet 3-20: Leadership
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